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OSCE Neuro Examine Cranial Nerves 8-12
Washes hands, appropriate dress and grooming. Introduces self, asks patient's name and age. Asks for consent * Hello my name is [Medical Student] and I'm a first year medical student at [Medical School], can I please get your full name and age please? * My Doe, today my attending physician has asked me to examine your cranial nerves, do I have your permission? Explains procedure to patient, positions and drapes * For today's examination, I'll be testing your hearing, parts of your mouth, and your shoulder muscles, are you comfortable with this? * I just want to remind you that anything we find will be confidential. * Is there anything I can get you before we begin? * The patient is sitting upright and is properly draped. INSPECT for: ear lesions or discharge, symmetrical soft palate, muscle asymmetry for the trapezius and sternocleidomastoid. * I'm going to check the patient's ear for lesions or discharge. ** I don't see any signs of lesions or discharge. * I'm going to stand behind the patient and check for symmetry of the trapezius muscles. ** Both trapezius muscles look symmetrical. * I'm now going to look for atrophy (wasting) or fasciculations (twitching) of the trapezius muscles. ** I don't see any signs of atrophy or fasciculations. * I'm now going to check for symmetry of the sternocleidomastoid muscle. ** Both sternocleidomastoid muscle look symmetrical. CN8: Perform WEBER and RINNE test and report findings. Describe what the findings of these tests would be for a conductive vs a sensory neural hearing loss. * Weber Test: ** I'm going to perform the Weber Test by placing the base the tuning fork on top the head to test bone conduction. ** Mr. Doe, can you hear sound in both ears? *** Sound heard in both ears is normal. * Rinne Test: ** I'm going to perform the Rinne Test by placing the base of the tuning fork on the mastoid bone. ** Mr. Doe, I'm going to place the tuning fork near your ear, please say "now" when you no longer hear the sound. ** *After the patient no longer hear the sound, place the prongs of the tuning fork near the ear* ** Can you still hear the sound? *** Yes means there's normal hearing. *** Normally sound is heard longer through air than through bone. **** (AC > BC) / Air Conduction > Bone Conduction * If '''Bone Conduction''' is '''greater''' than '''Air Conduction''' and sound is heard in the '''affected''' ear, this can suggest '''conductive''' hearing loss seen in: ** Otitis Media ** Eardrum Perforation ** Ear Canal Obstruction * If '''Air Conduction''' is '''greater''' than '''Bone Conduction''' and sound is '''heard''' in the '''good''' ear ''but'' '''not''' in the bad ear, this can suggest '''sensorineural hearing loss''' seen in: ** Constant exposure to loud noise ** Drugs ** Inner ear infection ** Aging * CN 9: Ask patient to say "ahhh" and comment on finding. * Please say "ahh" Mr. Doe. * *Use penlight* * I see symmetrical rise with the uvula at the midline which is normal. ** Asymmetrical rise can suggest unilateral Cranial X lesion. ** No rise can suggest bilateral Cranial Nerve X lesion. CN 10: Describe how to elicit a GAG REFLEX and neural pathway for this. * I'll like to take this time to talk about the GAG Reflex. * The GAG Reflex is elicited by stimulating the back of the throat lightly on each side with a Q-tip. * Unilateral absence of the Gag Reflex can suggest a Cranial Nerve X or XI lesion. CN 11: Asses strength of SCM and and trapezius and comment on findings * Mr. Doe, I'm going to stand in front of you and put my hands on your shoulder. * Please shrug your shoulders. * The patient was able to shrug his shoulders against resistance which is a normal sign. ** Trapezius weakness can suggest and disorder of the Peripheral Nervous System. ** Trapezius paralysis can suggest a Cranial Nerve 11 lesion. * Mr. Doe, I'm now going to put my hands on your face, please turn your head against my hand. ** The patient was able to turn his head against my hands which is normal. ** Trouble turning his head can suggest Sternocleidomastoid paralysis caused by a Cranial Nerve XI lesion. CN 12: Ask patient to PROTRUDE TONGUE and comment on findings. Describe findings on central CN 12 lesion. * Mr. Doe please stick out your tongue. * I do not see any deviation in the tongue. ** Deviation away from the side of the lesion can suggest a Central Cranial Nerve XII lesion. ** Deviation toward the side of lesion can suggest a Peripheral Cranial Nerve XII lesion. * That's the end of your exam, thank you for coming in. Knowledge Question